What to Do If Your Health Insurance Coverage is Denied
Mesothelioma is difficult and expensive to treat. If you have this condition, you have enough stress in your life. You don’t need unexpected, costly medical bills on top of that. A successful appeal may get you the coverage you need, and the outcome may make those bills disappear.
There are many types of health insurance. We will cover some tips for dealing with a private insurance coverage appeal. You can learn more from the Patient Advocate Foundation (PAF).
The following are links to information on appealing denials for other types of coverage:
The process can be lengthy and complex. Whether the denial is worth appealing depends on how critical the particular care is and how much money is at stake. Discuss with your physician other effective treatments the insurance company may accept.
You may reduce the chances of a denial by being treated by healthcare professionals who often treat mesothelioma patients. Over time they learn how insurance companies operate, what information they want, what they’ll cover, and what they won’t. They have “inside knowledge” that you lack.
What is Health Insurance? What’s an Appeal?
PAF suggests you learn the basic rules about your health insurance plan. It’s a contract that states in exchange for premiums, the insurance company will pay your healthcare costs, with restrictions.
The plan won’t pay for any kind of treatment under any circumstances, no matter the cost. Some treatments are excluded, and there are limits on what the company will pay.
Your appeal is to show what you want falls within the contract. Their decision may be terribly unfair and cause you a lot of grief. That doesn’t mean they lack the grounds to make it.
There are different levels to an appeal. Your appeal decided within the company may be rejected. You could then ask for an external review, which may agree with you. If it doesn’t go your way, you can file a complaint with the Kentucky Department of Commerce and Insurance, Division of Insurance. If there are sufficient grounds, you may sue your insurer.
Telling the company how upset you are will do you no good because it’s irrelevant. It’s all about their obligations under the plan and how they failed to live up to them.
What Coverage Was Denied and Why?
You need to know what went wrong before you can fix it. Your physician may have proposed a course of treatment, and the company stated they won’t pay for all or some of it (a prior authorization denial). They may also deny payment for a drug or treatment you already received.
Reasons for a denial may include:
- The treatment isn’t medically necessary
- The drug or therapy is off-formulary (not part of a prescription plan)
- The care involves an out-of-network provider
- The service isn’t a covered benefit under the plan
- You exceeded the benefit limits
- No pre-authorization was submitted
After you know the reason, you must show facts that establish they made the wrong decision.
Work With Your Doctor
Depending on the denial, you may need general medical information about your treatment (like why it’s not experimental) or information about your particular treatment (you used a drug because others didn’t work).
You’ll need to work with your doctor to build the evidence for your appeal. If the denial is based on the interpretation of plan language, you may need a lawyer to help you. The rejection may be a mistake. Your plan may not state what the company claims it does.
You must document your appeal. This may involve medical journal articles or other publications about the effectiveness of a particular treatment, or they show it’s the accepted way to treat mesothelioma. You may also need medical records showing your treatment and how it complies with the plan’s requirements
Plan Your Message
You, a medical provider, or your advocate can write your appeal. Discuss your diagnosis and your relevant treatment history. You’ll need to cover the plan language and, based on the facts, show that your position is correct and that they made a mistake.
You may have had extensive treatment and a long medical history. Keep it as short as possible while covering the necessary issues and points. Highlight the strengths of your position. Don’t bury them in a 20-page letter.
Don’t Miss the Deadline
Learn your deadline and meet it. Missing it gives the insurance company an excuse to reject your appeal and ignore the problem. Send your appeal package via certified
mail or with a tracking receipt so you can prove when it was received.
Satterley & Kelley represents mesothelioma survivors in legal claims against the asbestos industry. If you have mesothelioma and are having problems with your insurance, we can advise you and direct you to some helpful resources. Call us toll-free at 855-385-9532or fill out our contact form to schedule a free consultation.